Physical and Occupational Therapy Authorizations

In most cases, Horizon BCBSNJ authorizes the initial 25 visits of office and outpatient physical therapy or occupational therapy (PT/OT) services after receiving an initial claim from a participating physical or occupational therapist. A prior authorization for an initial 25 visits of office and outpatient PT/OT services is generally not necessary. However, eligibility and benefits must be confirmed prior to providing the service.

A prior authorization must be obtained in the following situations:

More than 25 visits are required.

Services are to be provided on an inpatient basis.

Services are to be provided to members enrolled in Medicare Advantage plans or to members enrolled in self-insured Administrative Services Only (ASO) accounts.

Diagnosis-related temporomandibular joint (TMJ) disorders.

Treatment for work-related injuries.

Patients under 19 years of age.

Pre-existing condition clause on the member’s policy.

All services from nonparticipating providers.

Prior authorizations can be requested using our online Physical and Occupational Therapy Authorization tool. To access this tool, log in to NaviNet.net, mouse over Referrals and Authorization and select Physical and Occupational Therapy Authorization.

The Physical and Occupational Therapy Authorization tool is for the use of rendering physical therapy and occupational therapy providers only. This tool cannot be used to create referrals for physical therapy or occupational therapy services.

Claims processing and reimbursement for services provided are subject to member eligibility and all member and group benefits, limitations and exclusions.

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